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Marais AD, Hoffman A, Blackhurst DM, van der Spuy ZM. Dyslipidaemia in women with polycystic ovary syndrome referred to a teaching hospital in Cape Town, South Africa. J Neuroendocrinol 2024:e13414. [PMID: 38858175 DOI: 10.1111/jne.13414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/02/2024] [Accepted: 05/11/2024] [Indexed: 06/12/2024]
Abstract
The polycystic ovary syndrome (PCOS) imparts health risks including dyslipidaemia, diabetes and cardiovascular disease that are amenable to lifestyle adjustment and/or medication. We describe dyslipidaemia in women referred to a gynaecological endocrine clinic. Clinical data and endocrine and lipoprotein investigations comprising fasting triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDLC) and calculated low density lipoprotein cholesterol (LDLC) were studied along with electrophoresis patterns of apolipoprotein B-containing lipoproteins. The 1721 participants comprised black, mixed ancestry, white and Indian individuals (9.8%, 83.2%, 5.8% and 1.2%, respectively). The mean ± standard deviation of the age, body mass index (BMI) and waist/hip ratio were 26.0 ± 5.9 years, 32.3 ± 8.3 kg/m2 and waist/hip ratio 0.88 ± 0.11, respectively. Overweight status (BMI 26-30 kg/m2) and obesity (BMI >30 kg/m2) involved 272 (15.8%) and 1010 (58.7%) individuals, respectively. Morbid obesity (BMI >40 kg/m2) was present in 309 (17.9%) individuals. The TG, TC, HDLC and LDLC concentrations were 1.22 ± 0.86, 4.77 ± 1.02, 1.3 ± 0.36, 2.94 ± 0.94 mmol/L, respectively. LDL hypercholesterolaemia occurred in 753 (43.7%) and exceeded 5 mmol/L in 39 (2.3%) women. Low HDLC (<0.9 mmol/L) affected 122 (7%), hypertriglyceridaemia (>1.7 mmol/L) affected 265 (15.4%) and exceeded 2.5 mmol/L in 91 (5.3%) women. Mixed hyperlipidaemia (TG >1.7, TC >5.0 mmol/L) occurred in 176 (10.2%). Electrophoresis revealed small LDL particles in 79 (4.6%) and dysbetalipoproteinaemia in 13 (0.76%) of the cohort. Small LDL associated with obesity, blood pressure, TG and glucose concentration and higher androgenic state. Many women with PCOS had unfavourable lipoprotein results: mostly moderate changes in TG, HDLC and LDLC. Small LDL is not rare, may aid risk assessment and is best determined directly. Incidental monogenic disorders of lipoprotein metabolism included dysbetalipoproteinaemia, familial hypercholesterolaemia and severe hypertriglyceridaemia. Dyslipidaemia in PCOS requires more careful diagnosis, individualised management and research.
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Affiliation(s)
- Adrian David Marais
- Chemical Pathology Division of Department of Pathology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Anne Hoffman
- Department of Obstetrics and Gynaecology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Diane Mary Blackhurst
- Chemical Pathology Division of Department of Pathology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Zephne Margeret van der Spuy
- Department of Obstetrics and Gynaecology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
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Bilgic S, Remaley AT, Sniderman AD. Triglyceride-rich lipoprotein cholesterol and cardiovascular risk. Curr Opin Lipidol 2023; 34:259-266. [PMID: 37773930 PMCID: PMC10872610 DOI: 10.1097/mol.0000000000000905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
PURPOSE OF REVIEW The triglyceride-rich apoB lipoprotein particles make up a minority of the apoB particles in plasma. They vary in size, in lipid, and in protein content. Most are small enough to enter the arterial wall and therefore most are atherogenic. But how important a contribution TRL particles make to the total risk created by the apoB lipoproteins remains controversial. A recent Mendelian randomization analysis determined that the cardiovascular risk related to the cholesterol within these apoB particles--the TRL cholesterol--was greater than--and independent of--the risk related to apoB. If correct, these observations have major clinical significance. RECENT FINDINGS Accordingly, we have analyzed these results in detail. In our view, the independent strength of the association between TRL cholesterol and apoB with cardiovascular risk seems inconsistent with the biological connections between apoB and cholesterol as integral and highly correlated constituents of apoB particles. These results are also inconsistent with other lines of evidence such as the results of the fibrate randomized clinical trials. Moreover, we are also concerned with other aspects of the analysis. SUMMARY We do not regard the issue as settled. However, this enquiry has led us to a fuller understanding of the determinants of the cholesterol content of the TRL apoB particles and the complex processing of cholesterol amongst the plasma lipoproteins.
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Affiliation(s)
- Selin Bilgic
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alan T. Remaley
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Allan D. Sniderman
- Mike and Valeria Rosenbloom Centre for Cardiovascular Prevention, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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Paquette M, Blais C, Fortin A, Bernard S, Baass A. Dietary recommendations for dysbetalipoproteinemia: A need for better evidence. J Clin Lipidol 2023; 17:549-556. [PMID: 37268489 DOI: 10.1016/j.jacl.2023.05.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023]
Abstract
The increased risk of cardiovascular disease in patients with dysbetalipoproteinemia (DBL) is well documented and is associated with the dysfunctional metabolism of remnant lipoproteins. Although these patients are known to respond well to lipid-lowering medication including statins and fibrates, the best dietary approach to lower remnant lipoprotein accumulation and to prevent cardiovascular outcomes remain unclear. Indeed, current evidence is based on studies published mainly in the 1970s, which comprise small sample sizes and methodological limitations. This review aims to summarize nutritional studies performed in DBL patients to date and to discuss potential avenues in this field and future areas of research.
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Affiliation(s)
- Martine Paquette
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Chantal Blais
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Andréanne Fortin
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada
| | - Sophie Bernard
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada; Department of Medicine, Division of Endocrinology, University of Montreal, Montreal, Québec, Canada; Research Centre of the Centre Hospitalier Universitaire de Montréal (CRCHUM), Montreal, Québec, Canada
| | - Alexis Baass
- Genetic Dyslipidemias Clinic of the Montreal Clinical Research Institute, Montreal, Québec, Canada; Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montreal, Québec, Canada.
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4
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Hyperlipidemia and Cardiovascular Risk in Children and Adolescents. Biomedicines 2023; 11:biomedicines11030809. [PMID: 36979789 PMCID: PMC10045454 DOI: 10.3390/biomedicines11030809] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 02/26/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) represents the major cause of morbidity and mortality worldwide. The onset of the atherosclerosis process occurs during childhood and adolescence, subsequently leading to the onset of cardiovascular disease as young adults. Several cardiovascular risk factors can be identified in children and adolescents; however, hyperlipidemia, in conjunction with the global obesity epidemic, has emerged as the most prevalent, playing a key role in the development of ASCVD. Therefore, screening for hyperlipidemia is strongly recommended to detect high-risk children presenting with these disorders, as these patients deserve more intensive investigation and intervention. Treatment should be initiated as early as possible in order to reduce the risk of future ASCVD. In this review, we will discuss lipid metabolism and hyperlipidemia, focusing on correlations with cardiovascular risk and screening and therapeutic management to reduce or almost completely avoid the development of ASCVD.
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Bea AM, Cenarro A, Marco-Bened V, Laclaustra M, Martn C, Ibarretxe D, Pint X, Arrobas T, Vials C, Civeira F, Olmos S. Diagnosis of Familial Dysbetalipoproteinemia Based on the Lipid Abnormalities Driven by APOE2/E2 Genotype. Clin Chem 2023; 69:140-148. [PMID: 36644927 DOI: 10.1093/clinchem/hvac213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/14/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Familial dysbetalipoproteinemia (FDBL) is a monogenic disease due to variants in APOE with a highly variable phenotype. Current diagnostic lipid-based methods have important limitations. The objective is twofold: to define characteristics of dysbetalipoproteinemia (DBL) based on the analysis of APOE in patients from a lipid unit and in a sample from the general population, and to propose a screening algorithm for FDBL. METHODS Lipids and APOE genotype from consecutive unrelated subjects from Miguel Servet University Hospital (MSUH) (n 3603), subjects from the general population participants of the Aragon Workers Health Study (AWHS) (n 4981), and selected subjects from external lipid units (Ext) (n 390) were used to define DBL criteria and to train and validate a screening tool. RESULTS Thirty-five subjects from MSUH, 21 subjects from AWHS, and 31 subjects from Ext were APOE2/2 homozygous. The combination of non high-density lipoprotein cholesterol (non-HDLc)/apoB 1.7 plus triglycerides/apoB 1.35, in mg/dL (non-HDLc [mmol/L]/apolipoprotein B (apoB) [g/L] 4.4 and triglycerides [mmol/L]/apoB [g/L] 3.5), provided the best diagnostic performance for the identification of subjects with hyperlipidemia and APOE2/2 genotype (sensitivity 100 in the 3 cohorts, and specificity 92.8 [MSUH], 80.9 [AWHS], and 77.6 [Ext]). This improves the performance of previous algorithms. Similar sensitivity and specificity were observed in APOE2/2 subjects receiving lipid-lowering drugs. CONCLUSIONS The combination of non-HDLc/apoB and triglycerides/apoB ratios is a valuable tool to diagnose DBL in patients with hyperlipidemia with or without lipid-lowering drugs. FDBL diagnosis requires DBL and the presence of a compatible APOE genotype. Most adult APOE2/2 subjects express DBL, making FDBL as common as familial hypercholesterolemia in the population.
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Affiliation(s)
- Ana M Bea
- Hospital Universitario Miguel Servet, IIS Aragn, CIBERCV, Zaragoza, Spain
| | - Ana Cenarro
- Hospital Universitario Miguel Servet, IIS Aragn, CIBERCV, Zaragoza, Spain.,Molecular Research Laboratory, Instituto Aragones de Ciencias de la Salud (IACS), Zaragoza, Spain
| | - Victoria Marco-Bened
- Hospital Universitario Miguel Servet, IIS Aragn, CIBERCV, Zaragoza, Spain.,Departamento de Medicina, Psiquiatra y Dermatologa, Universidad de Zaragoza, Zaragoza, Spain
| | - Martn Laclaustra
- Hospital Universitario Miguel Servet, IIS Aragn, CIBERCV, Zaragoza, Spain.,Departamento de Medicina, Psiquiatra y Dermatologa, Universidad de Zaragoza, Zaragoza, Spain
| | - Csar Martn
- Fundacin Biofisika Bizkaia, Leioa, Spain.,Biofisika Institute (UPV/EHU, CSIC), Leioa, Spain.,Department of Biochemistry and Molecular Biology, Universidad del Pas Vasco UPV/EHU, Bilbao, Spain
| | - Daiana Ibarretxe
- Unitat de Medicina Vascular i Metabolisme (UVASMET) Hospital Universitari Sant Joan, IISPV, CIBERDEM, Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Xavier Pint
- Unidad de Lpidos, Servicio de Medicina Interna, Hospital Universitario de Bellvitge-Idibell, Universidad de Barcelona, CiberObn, Barcelona, Spain
| | - Teresa Arrobas
- Laboratorio de Nutricin y RCV, Laboratorio de Bioqumica Clnica, Hospital Virgen Macarena, Sevilla, Spain
| | - Clara Vials
- Endocrinology Department, Hospital Clnic de Barcelona, Barcelona, Spain.,Institut dInvestigacions Biomdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacin Biomdica en Red Fisiopatologa de la Obesidad y Nutricin (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Fernando Civeira
- Hospital Universitario Miguel Servet, IIS Aragn, CIBERCV, Zaragoza, Spain.,Departamento de Medicina, Psiquiatra y Dermatologa, Universidad de Zaragoza, Zaragoza, Spain
| | - Salvador Olmos
- Hospital Universitario Miguel Servet, IIS Aragn, CIBERCV, Zaragoza, Spain.,Aragon Institute of Engineering Research (I3A), Universidad de Zaragoza, Zaragoza, Spain
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Paquette M, Bernard S, Baass A. Dysbetalipoproteinemia Is Associated With Increased Risk of Coronary and Peripheral Vascular Disease. J Clin Endocrinol Metab 2022; 108:184-190. [PMID: 36056815 DOI: 10.1210/clinem/dgac503] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/12/2022] [Indexed: 02/03/2023]
Abstract
CONTEXT Dysbetalipoproteinemia (DBL) is a disorder in which remnant lipoproteins accumulate in the plasma due to a genetic apolipoprotein E dysfunction in conjunction with the presence of secondary metabolic factors. An increased risk of both coronary and peripheral vascular disease (PVD) has been observed in these patients in retrospective studies. OBJECTIVE The primary objective was to compare the incidence of atherosclerotic cardiovascular disease (ASCVD) and PVD in a cohort of patients with DBL compared with normolipidemic controls. As a secondary objective, the incidence of ASCVD and PVD was compared between patients with DBL and patients with familial hypercholesterolemia (FH). METHODS A total of 221 patients with DBL, 725 patients with FH, and 1481 normolipidemic controls were included in the study. The data were obtained by review of medical records. RESULTS In patients with DBL, there was an overall excess risk of PVD (hazard ratio [HR] 13.58, 95% CI 4.76-38.75) and ASCVD (HR 3.55, 95% CI 2.17-5.83) (P < .0001) when compared with normolipidemic controls. When compared with patients with FH, an increased risk of PVD (HR 3.89, 95% CI 1.20-12.55, P = .02) was observed in patients with DBL. CONCLUSION We demonstrated that the risks of ASCVD and PVD in DBL are >3-fold and >13-fold higher, respectively, than normolipidemic controls. Furthermore, the risk of PVD is ∼4-fold higher in DBL than in FH. Adequate screening of DBL is imperative to improve the clinical care of these patients by preventing the development of ASCVD.
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Affiliation(s)
- Martine Paquette
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada
| | - Sophie Bernard
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada
- Department of Medicine, Division of Endocrinology, Université de Montreal, Montreal, QC, Canada
| | - Alexis Baass
- Lipids, Nutrition, and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Montreal, QC, Canada
- Department of Medicine, Divisions of Experimental Medicine and Medical Biochemistry, McGill University, Montreal, QC, Canada
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Abstract
PURPOSE OF REVIEW The functions, genetic variations and impact of apolipoprotein E on lipoprotein metabolism in general are placed in the context of clinical practice dealing with moderate dyslipidaemia as well as dysbetalipoproteinemia, a highly atherogenic disorder and lipoprotein glomerulopathy. RECENT FINDINGS Additional variants of apolipoprotein E and participation of apolipoprotein E in inflammation are of interest. The mostly favourable effects of apolipoprotein E2 as well as the atherogenic nature of apolipoproteinE4, which has an association with cognitive impairment, are confirmed. The contribution of remnant lipoproteins of triglyceride-rich lipoproteins, of which dysbetalipoproteinemia represents an extreme, is explored in atherosclerosis. Mimetic peptides may present new therapeutic approaches. Apolipoprotein E is an important determinant of the lipid profile and cardiovascular health in the population at large and can precipitate dysbetalipoproteinemia and glomerulopathy. Awareness of apolipoprotein E polymorphisms should improve medical care.
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Cenarro A, Bea AM, Gracia-Rubio I, Civeira F. Dysbetalipoproteinemia and other lipid abnormalities related to apo E. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2021; 33 Suppl 2:50-55. [PMID: 34006354 DOI: 10.1016/j.arteri.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 01/10/2021] [Indexed: 11/30/2022]
Abstract
Dysbetalipoproteinaemia (or type III hyperlipoproteinaemia) is a severe mixed hyperlipidaemia resulting from the accumulation of remnant chylomicron and VLDL particles in plasma, also called β-VLDL. It is caused by a defect in the recognition by hepatic LDL and lipoprotein receptor-related protein (LRP) of β-VLDL. Mutations in the APOE gene, especially in subjects homozygous for the ɛ2/ɛ2 allele, are responsible for this lack of receptor recognition. Dysbetalipoproteinaemia represents 2-5% of the mixed dyslipidaemias seen in Lipid Units, is highly atherogenic and predisposes to diffuse atheromatosis, either coronary, peripheral vascular, or carotid, so early diagnosis and treatment is necessary. The presence of hypertriglyceridaemia, with non-HDL cholesterol/apolipoprotein B ratios>1.43 (in mg/dL) followed by APOE genotyping is the method of choice in the diagnosis of dysbetalipoproteinaemia. It is a dyslipidaemia that responds well to hygienic-dietary treatment, although the combination of statin and fenofibrate is often necessary to achieve optimal control.
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Affiliation(s)
- Ana Cenarro
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Universidad de Zaragoza, Zaragoza, España
| | - Ana M Bea
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Universidad de Zaragoza, Zaragoza, España
| | - Irene Gracia-Rubio
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Universidad de Zaragoza, Zaragoza, España
| | - Fernando Civeira
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital Universitario Miguel Servet, IIS Aragón, CIBERCV, Universidad de Zaragoza, Zaragoza, España.
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Bell JA, Santos Ferreira DL, Fraser A, Soares ALG, Howe LD, Lawlor DA, Carslake D, Davey Smith G, O'Keeffe LM. Sex differences in systemic metabolites at four life stages: cohort study with repeated metabolomics. BMC Med 2021; 19:58. [PMID: 33622307 PMCID: PMC7903597 DOI: 10.1186/s12916-021-01929-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/27/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Males experience higher rates of coronary heart disease (CHD) than females, but the circulating traits underpinning this difference are poorly understood. We examined sex differences in systemic metabolites measured at four life stages, spanning childhood to middle adulthood. METHODS Data were from the Avon Longitudinal Study of Parents and Children (7727 offspring, 49% male; and 6500 parents, 29% male). Proton nuclear magnetic resonance (1H-NMR) spectroscopy from a targeted metabolomics platform was performed on EDTA-plasma or serum samples to quantify 229 systemic metabolites (including lipoprotein-subclass-specific lipids, pre-glycaemic factors, and inflammatory glycoprotein acetyls). Metabolites were measured in the same offspring once in childhood (mean age 8 years), twice in adolescence (16 years and 18 years) and once in early adulthood (25 years), and in their parents once in middle adulthood (50 years). Linear regression models estimated differences in metabolites for males versus females on each occasion (serial cross-sectional associations). RESULTS At 8 years, total lipids in very-low-density lipoproteins (VLDL) were lower in males; levels were higher in males at 16 years and higher still by 18 years and 50 years (among parents) for medium-or-larger subclasses. Larger sex differences at older ages were most pronounced for VLDL triglycerides-males had 0.19 standard deviations (SD) (95% CI = 0.12, 0.26) higher at 18 years, 0.50 SD (95% CI = 0.42, 0.57) higher at 25 years, and 0.62 SD (95% CI = 0.55, 0.68) higher at 50 years. Low-density lipoprotein (LDL) cholesterol, apolipoprotein-B, and glycoprotein acetyls were generally lower in males across ages. The direction and magnitude of effects were largely unchanged when adjusting for body mass index measured at the time of metabolite assessment on each occasion. CONCLUSIONS Our results suggest that males begin to have higher VLDL triglyceride levels in adolescence, with larger sex differences at older ages. Sex differences in other CHD-relevant metabolites, including LDL cholesterol, show the opposite pattern with age, with higher levels among females. Such life course trends may inform causal analyses with clinical endpoints in specifying traits which underpin higher age-adjusted CHD rates commonly seen among males.
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Affiliation(s)
- Joshua A Bell
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Diana L Santos Ferreira
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Abigail Fraser
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ana Luiza G Soares
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Laura D Howe
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - David Carslake
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - George Davey Smith
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - Linda M O'Keeffe
- MRC Integrative Epidemiology Unit at the University of Bristol, Oakfield House, Bristol, BS8 2BN, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- School of Public Health, Western Gateway Building, University College Cork, Cork, Ireland
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Varghese B, Park J, Chew E, Sajja A, Brownstein A, Pallazola VA, Sathiyakumar V, Jones SR, Sniderman AD, Martin SS. Importance of the triglyceride level in identifying patients with a Type III Hyperlipoproteinemia phenotype using the ApoB algorithm. J Clin Lipidol 2021; 15:104-115.e9. [PMID: 33189625 DOI: 10.1016/j.jacl.2020.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hyperlipoproteinemia Type III (HLP3), also known as dysbetalipoproteinemia, is defined by cholesterol and triglyceride (TG) enriched remnant lipoprotein particles (RLP). The gold standard for diagnosis requires demonstration of high remnant lipoprotein particle cholesterol (RLP-C) by serum ultracentrifugation (UC), which is not readily available in daily practice. The apoB algorithm can identify HLP3 using total cholesterol (TC), plasma triglyceride (TG), and apoB. However, the optimal TG cutoff is unknown. OBJECTIVE We analyzed apoB algorithm defined HLP3 at different TG levels to optimize the TG cutoff for the algorithm. METHODS 128,485 UC lipid profiles in the Very Large Database of Lipids (VLDbL) were analyzed. RLP-C was assessed at TG ≥ 133 mg/dL, ≥175 mg/dL, ≥200 mg/dL, and ≥ 250 mg/dL. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and prevalence adjusted and bias-adjusted kappa (PABAK) were calculated against UC Criterion (VLDL-C/TG ≥ 0.25) for HLP3. RESULTS The median age (IQR) was 57 years (46-68). 45% were men, 20.1% had diabetes, and 25.5% had hypertension. The median RLP-C level for the TG cutoffs (mg/dL) of ≥ 133, ≥ 175, ≥ 200, and ≥ 250 were 34, 43, 50, and 62 mg/dL, respectively, compared to 67 mg/dL in UC defined HLP3. TG ≥ 133 mg/dL yielded optimal results (Sn 29.5%, Sp 98.5%, PABAK 0.96, PPV 13.6%, NPV 99.4%). CONCLUSION TG ≥ 133 mg/dL allows for high sensitivity in screening for HLP3. Higher TG cutoffs may identify more severe HLP3 phenotypes, but with a large loss in sensitivity for HLP3.
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Affiliation(s)
- Bibin Varghese
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jihwan Park
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin Chew
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aparna Sajja
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adam Brownstein
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vincent A Pallazola
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vasanth Sathiyakumar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R Jones
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan D Sniderman
- Mike and Valeria Centre for Cardiovascular Prevention, McGill University Health Centre, Montreal, Quebec, Canada
| | - Seth S Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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11
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Paquette M, Bernard S, Blank D, Paré G, Baass A. A simplified diagnosis algorithm for dysbetalipoproteinemia. J Clin Lipidol 2020; 14:431-437. [DOI: 10.1016/j.jacl.2020.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/26/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
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12
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Boot CS, Luvai A, Neely RDG. The clinical and laboratory investigation of dysbetalipoproteinemia. Crit Rev Clin Lab Sci 2020; 57:458-469. [PMID: 32255405 DOI: 10.1080/10408363.2020.1745142] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Familial dysbetalipoproteinemia (type III hyperlipoproteinemia) is a potentially underdiagnosed inherited dyslipidemia associated with greatly increased risk of coronary and peripheral vascular disease. The mixed hyperlipidemia observed in this disorder usually responds well to appropriate medical therapy and lifestyle modification. Although there are characteristic clinical features such as palmar and tuberous xanthomata, associated with dysbetalipoproteinemia, they are not always present, and their absence cannot be used to exclude the disorder. The routine lipid profile cannot distinguish dysbetalipoproteinemia from other causes of mixed hyperlipidemia and so additional investigations are required for confident diagnosis or exclusion. A range of investigations that have been proposed as potential diagnostic tests are discussed in this review, but the definitive biochemical test for dysbetalipoproteinemia is widely considered to be beta quantification. Beta quantification can determine the presence of "β-VLDL" in the supernatant following ultracentrifugation and whether the VLDL cholesterol to triglyceride ratio is elevated. Both features are considered hallmarks of the disease. However, beta quantification and other specialist tests are not widely available and are not high-throughput tests that can practically be applied to all patients with mixed hyperlipidemia. Using apolipoprotein B (as a ratio either to total or non-HDL cholesterol or as part of a multi-step algorithm) as an initial test to select patients for further investigation is a promising approach. Several studies have demonstrated a high degree of diagnostic sensitivity and specificity using these approaches and apolipoprotein B is a relatively low-cost test that is widely available on high-throughput platforms. Genetic testing is also important in the diagnosis, but it should be noted that most individuals with an E2/2 genotype do not suffer from remnant hyperlipidemia and around 10% of familial dysbetalipoproteinemia cases are caused by rarer, autosomal dominant mutations in APOE that will only be detected if the gene is fully sequenced. Wider implementation of diagnostic pathways utilizing apo B could lead to more rational use of specialist investigations and more consistent detection of patients with dysbetalipoproteinemia. Without the application of a consistent evidence-based approach to identifying dysbetalipoproteinemia, many cases are likely to remain undiagnosed.
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Affiliation(s)
- Christopher S Boot
- Department of Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ahai Luvai
- Department of Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Robert D G Neely
- Department of Blood Sciences, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Pallazola VA, Sathiyakumar V, Park J, Vakil RM, Toth PP, Lazo-Elizondo M, Brown E, Quispe R, Guallar E, Banach M, Blumenthal RS, Jones SR, Marais D, Soffer D, Sniderman AD, Martin SS. Modern prevalence of dysbetalipoproteinemia (Fredrickson-Levy-Lees type III hyperlipoproteinemia). Arch Med Sci 2020; 16:993-1003. [PMID: 32863987 PMCID: PMC7444722 DOI: 10.5114/aoms.2019.86972] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Dysbetalipoproteinaemia (HLP3) is a disorder characterized by excess cholesterol-enriched, triglyceride-rich lipoprotein remnants in genetically predisposed individuals that powerfully promote premature cardiovascular disease if untreated. The current prevalence of HLP3 is largely unknown. MATERIAL AND METHODS We performed cross-sectional analysis of 128,485 U.S. adults from the Very Large Database of Lipids (VLDbL), using four algorithms to diagnose HLP3 employing three Vertical Auto Profile ultracentrifugation (UC) criteria and a previously described apolipoprotein B (apoB) method. We evaluated 4,926 participants from the 2011-2014 National Health and Nutrition Examination Survey (NHANES) with the apoB method. We examined demographic and lipid characteristics stratified by presence of HLP3 and evaluated lipid characteristics in those with HLP3 phenotype discordance and concordance as determined by apoB and originally defined UC criteria 1. RESULTS In U.S. adults in VLDbL and NHANES, a 1.7-2.0% prevalence is observed for HLP3 with the novel apoB method as compared to 0.2-0.8% prevalence in VLDbL via UC criteria 1-3. Participants who were both apoB and UC criteria HLP3 positive had higher remnant particles as well as more elevated triglyceride/apoB and total cholesterol/apoB ratios (all p < 0.001) than those who were apoB method positive and UC criteria 1 negative. CONCLUSIONS HLP3 may be more prevalent than historically and clinically appreciated. The apoB method increases HLP3 identification via inclusion of milder phenotypes. Further work should evaluate the clinical implications of HLP3 diagnosis at various lipid algorithm cut-points to evaluate the ideal standard in the modern era.
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Affiliation(s)
- Vincent A. Pallazola
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vasanth Sathiyakumar
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jihwan Park
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rachit M. Vakil
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter P. Toth
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, Community Hospital General Medical Center, Sterling, IL, USA
| | - Mariana Lazo-Elizondo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily Brown
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Renato Quispe
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eliseo Guallar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maciej Banach
- Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
| | - Roger S. Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R. Jones
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Marais
- Department of Internal Medicine, University of Cape Town Health Sciences, Cape Town, South Africa
| | - Daniel Soffer
- Department of Medicine and Institute for Translational Medicine and Therapeutics, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Allan D. Sniderman
- Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Seth S. Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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14
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Paquette M, Bernard S, Paré G, Baass A. Triglycerides, hypertension, and smoking predict cardiovascular disease in dysbetalipoproteinemia. J Clin Lipidol 2019; 14:46-52. [PMID: 31959563 DOI: 10.1016/j.jacl.2019.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/18/2019] [Accepted: 12/18/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Dysbetalipoproteinemia (DBL) is an autosomal recessive lipid disorder associated with a reduced clearance of remnant lipoproteins and is associated with an increased cardiovascular disease (CVD) risk. The genetic cause of DBL is apoE2 homozygosity in 90% of cases. However, a second metabolic hit must be present to precipitate the disease. However, no study has investigated the predictors of CVD, peripheral artery disease and coronary artery disease in a large cohort of patients with DBL. OBJECTIVE The objectives of this study were to describe the clinical characteristics of a DBL cohort and to identify the predictors of CVD, peripheral artery disease, and coronary artery disease in this population. METHODS The inclusion criteria included age ≥ 18 years, apoE2/E2, triglycerides (TG) > 135 mg/dL and VLDL-C/plasma TG ratio > 0.30. RESULTS We studied 221 adult DBL patients, of which 51 (23%) had a history of CVD. We identified 3 independent predictors of CVD, namely hypertension (OR 5.68, 95% CI 2.13-15.16, P = .001), pack year of smoking (OR 1.03, 95% CI 1.01-1.05, P = .01) and TG tertile (OR 1.82, 95% CI 1.09-3.05, P = .02). The CVD prevalence was 51% in patients with hypertension and 18% in those without hypertension (P = .00001), and 30% in the highest TG tertile vs 15% in the lowest tertile (P = .04). Similarly, the CVD prevalence was higher in heavy smokers compared with nonsmokers (36% vs 13%, P = .006). CONCLUSION Hypertension, smoking, and TG are independently associated with CVD risk in patients with DBL. Aggressive treatment should be initiated in patients with DBL because of the increased risk of CVD.
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Affiliation(s)
- Martine Paquette
- Lipids, Nutrition and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Québec, Canada
| | - Sophie Bernard
- Lipids, Nutrition and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Québec, Canada; Division of Endocrinology, Department of Medicine, Université de Montreal, Québec, Canada
| | - Guillaume Paré
- Genetic Molecular Epidemiology Lab, Population Health Research Institute, Ontario, Canada
| | - Alexis Baass
- Lipids, Nutrition and Cardiovascular Prevention Clinic of the Montreal Clinical Research Institute, Québec, Canada; Divisions of Experimental Medicine and Medical Biochemistry, Department of Medicine, McGill University, Québec, Canada.
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Stone NJ, Grundy SM. The 2018 AHA/ACC/Multi-Society Cholesterol guidelines: Looking at past, present and future. Prog Cardiovasc Dis 2019; 62:375-383. [PMID: 31733217 DOI: 10.1016/j.pcad.2019.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 01/09/2023]
Abstract
The authors review more than three decades of progress in providing clinicians and patients with guidance on risk assessment, patient evaluation and cholesterol management. Beginning with the National Cholesterol Education Program's Initial Adult Treatment Panel report, the cholesterol guidelines increasingly reflect the progress made in understanding the benefits of improved lifestyle and nutrition to improve lipid profiles, major risk factors and reduce ASCVD risk. Moreover, they now provide qualitative and quantitative assessment tools to guide appropriate risk reduction LDL-C lowering therapy. Use of the Pooled Cohort Equations to determine Low, Borderline, Intermediate and High 10-year ASCVD risk is now joined by recognition of conditions and biomarkers that enhance ASCVD risk. This personalizes the risk discussion for the patient. An important addition is the selective use of coronary artery calcium (CAC) scoring to reclassify risk in patients at borderline or intermediate risk, but for whom a risk decision regarding statin therapy is uncertain. In secondary prevention, current guidelines provide criteria for determining a "very high" risk group in whom risk is especially high and in whom aggressive LDL-C lowering can be shown to provide increased absolute benefit. Current guidelines provide a comprehensive look at children and adolescents, young adults, elderly, women and issues specific to women through the life course. They provide guidance for those adults at risk due to severe hypercholesterolemia, persistent hypertriglyceridemia after secondary causes have been addressed, those with inflammatory disorders and HIV, those adults with chronic kidney disease, and those affected by issues of race/ethnicity. They conclude with a brief summary of recommendations emphasizing important concepts for providing safety with LDL-C lowering therapy. This combination of best external evidence and clinical expertise from the expert panel should provide a solid foundation for lipid management of patients at risk for or with clinical ASCVD.
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Affiliation(s)
- Neil J Stone
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America.
| | - Scott M Grundy
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, United States of America
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